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BACKGROUND

  • Cardiac arrest is defined by a triad of derangements:

    • Pulselessness

    • Apnea

    • Unresponsiveness

  • This state leads to progressive tissue ischemia and organ dysfunction, which, if not rapidly corrected, can result in irreversible deterioration of cardiac and neurologic function.

  • Cardiac arrest occurs in 2% to 6% of pediatric patients who are admitted to the pediatric intensive care unit.

  • Cardiac arrest occurs in approximately 16,000 children out of hospital in the United States each year.

  • Because of the relative infrequency of out-of-hospital events, pediatric resuscitations are not common for providers outside of the pediatric intensive care unit.

  • There continues to be a significant difference in outcomes (e.g., favorable vs. nonfavorable) between patients with in-hospital vs. out-of-hospital events.

ETIOLOGY

  • In general, the cause of cardiac arrest falls into one of three categories:

    • Asphyxia

    • Ischemia

    • Arrhythmia

  • Adults with cardiac arrest often have sudden, unexpected ventricular fibrillation and often have underlying coronary artery disease, which leads to myocardial ischemia.

  • In contrast, pediatric cardiac arrest is rarely caused by a sudden coronary event or arrhythmia.

  • Cardiac arrest in children is most often caused by progressive asphyxia from acute hypoxia or hypercarbia, which leads to acidosis and nutrient depletion.

  • Ischemic events are the second most common etiology in pediatrics.

  • Ischemic events occur secondary to inadequate myocardial oxygen delivery, which in children occurs most commonly in the setting of sepsis, hypovolemia, or myocardial dysfunction.

  • Arrhythmias account for the smallest number of cardiac arrest events in pediatric patients, comprising only 10% of events.

PHASES OF CARDIAC ARREST

  • Cardiac arrest can be broken down into four phases:

    • Prearrest

    • No flow (untreated cardiac arrest)

    • Low flow (cardiopulmonary resuscitation [CPR])

    • Postresuscitation

PREARREST

  • Pediatric patients with in-hospital cardiac arrest may have physiologic changes in the hours leading up to their arrest.

  • Because the majority of pediatric cardiac arrests occur secondary to progressive asphyxia or ischemia, recognition and treatment of respiratory failure and shock states may prevent a number of arrest events from occurring.

  • The Pediatric Advanced Life Support (PALS) course was designed to reduce the number of cardiac arrests by improving the early recognition of these conditions.

  • Care during this phase should focus on:

    • Identifying and treating reversible conditions

    • Optimizing patient monitoring

    • Providing rapid emergency response for patients not already in a health care setting

NO FLOW (UNTREATED CARDIAC ARREST)

  • During untreated cardiac arrest, circulation has stopped.

  • Responders to cardiac arrest should minimize time in this state in order to optimize patient outcomes.

  • Interventions should focus on the initiation of Basic and Advanced Life Support techniques.

LOW FLOW (CPR)

  • The low-flow phase begins with the initiation of resuscitation measures (chest compressions).

  • Effective CPR improves coronary perfusion pressure and provides cardiac output to support organ viability.

  • Even with optimal CPR, cardiac output is only 10% to 25% of normal. Basic Life Support ...

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